“Why a patient paid a $285 copay for a $40 drug

Two years ago Gretchen Liu, 78, had a transient ischemic attack — which experts sometimes call a “mini stroke” — while on a trip to China. After she recovered and returned home to San Francisco, her doctor prescribed a generic medication called telmisartan to help manage her blood pressure. Liu and her husband Z. Ming Ma, a retired physicist, are insured through an Anthem Medicare plan. Ma ordered the telmisartan through Express Scripts, the company that manages pharmacy benefits for Anthem and also provides a mail-order service.

The copay for a 90-day supply was $285, which seemed high to Ma.

“I couldn’t understand it — it’s a generic,” said Ma. “But it was a serious situation, so I just got it.” A month later, Ma and his wife were about to leave on another trip, and Ma needed to stock up on her medication. Because 90 days hadn’t yet passed, Anthem wouldn’t cover it. So during a trip to his local Costco, Ma asked the pharmacist how much it would cost if he got the prescription there and paid out of pocket. The pharmacist told him it would cost about $40 “I was very shocked,” said Ma. “I had no idea if I asked to pay cash, they’d give me a different price.” Ma’s experience of finding a copay higher than the cost of the drug wasn’t that unusual. Insurance copays are higher than the cost of the drug about 25 percent of the time, according to a study published in March by the University of Southern California’s Schaeffer Center for Health Policy and Economics. USC researchers analyzed 9.5 million prescriptions filled during the first half of 2013. They compared the copay amount to what the pharmacy was reimbursed for the medication and found in the cases where the copay was higher, the overpayments averaged $7.69, totaling $135 million that year.

USC economist Karen Van Nuys, a lead author of the study, had her own story of overpayment. She discovered she could buy a one-year supply of her generic heart medication for $35 out of pocket instead of $120 using her health insurance.”

I act as guardian for my mother who has both Medicare & Tricare coverage. I just received a detailed account of my mother’s medications for RX this year. There is an “*” on each line item. The note at the bottom of the statement reads as follows: “You can use home delivery from the TRICARE Mail Order Pharmacy for this medication and receive a 90 day supply for less than the 30 day supply co-pay from a retail pharmacy. Shipping is free……..”

I am shocked by this. As a tax payer you should be also. Obviously planned overpayments to pharmacies (with possible collusion by insurance companies) is horrible and in my view constitutes both fraud and an additional “tax” to consumers. However, keep in mind that these are examples were the Co-pay is higher than the retail value of the drug. This is not merely an “overpayment” but outright theft. The attempt at explanations, in my view, are ludicrous. I encourage you to form your own view by reading the entire article at: https://www.pbs.org/newshour/health/why-a-patient-paid-a-285-copay-for-a-40-drug